Obesity and pregnancy: complications and cost

A population-based risk factor scoring will decrease unnecessary testing for the diagnosis of gestational diabetes mellitus

BACKGROUND

To determine the effectiveness of a population-based risk factor scoring to decrease unnecessary testing for the diagnosis of gestational diabetes mellitus (GDM).

METHODS

We formed a risk factor scoring over five, which questions maternal age, body mass index and first-degree relatives with a diagnosis of diabetes mellitus, a prior macrosomic fetus and adverse outcome during the previous pregnancies. All participants underwent a 50-g glucose challenge test (GCT) followed by a 100-g oral glucose tolerence test (OGTT). We opened the 50-g GCT envelope if the participant had a risk score > or = 1 and opened the 100-g OGTT envelope if the 50-g GCT value was > or = 7.2 mmol/l. After all patients delivered we also built other strategies and tested their detection rates.

RESULTS

Fourteen patients (3.3%) were diagnosed as having gestational diabetes mellitus via a 100-g OGTT. None of the patients with a score of zero had gestational diabetes mellitus. Logistic regression analysis revealed that an increase in the score by one caused a three times increase in gestational diabetes mellitus risk (OR = 3, CI = 1.9-5). Compared with the universal screening, our strategy to screen if the risk score was > or = 1, followed by a 50-g GCT with a 7.2-mmol/l cut-off value, decreased the number of women to be screened by 30% and diagnosed all cases with GDM. Screening the patients with a score > or = 2 would have decreased the number of women to be screened by 63%, still diagnosing 85% of cases with GDM. Also, risk factor-based screening strategies cause a 50% and 53% reduction in the number of OGTT applied, respectively.

CONCLUSION

A well integrated, population-based scoring will decrease the number of unnecessary testing but still diagnose 85-100% of GDM cases.

Proactive management of menstrual cycle abnormalities in young women

The goal of an integrative science of women's health is bringing together childbearing with women's health during the lifespan. Enhancing a woman's ability to conceive and maintain a pregnancy is influenced by decisions made well before the beginning of a pregnancy. Identifying ovulatory disorders makes it possible to intervene early in a young woman's childbearing years. Gynecologic charting typically used in natural family planning provides information to the woman and to the healthcare provider that is useful for diagnosis. If young women have a better understanding of fertility and menstrual cycle function, they are in a stronger position to make informed decisions about how they wish to manage their reproductive and sexual health. It may be possible to educate the young woman in health habits that will lead to a healthy pregnancy when she chooses and/or to treat the cause of the ovulatory disorder. This article focuses on polycystic ovary syndrome and hypothalamic dysfunction which can cause menstrual cycle abnormalities in which gynecologic charting is useful in young women.

The influence of obesity and gestational diabetes mellitus on accretion and the distribution of adipose tissue in pregnancy

OBJECTIVE

The purpose of this study was to evaluate the effect of pregravid obesity and gestational diabetes mellitus (GDM) on the longitudinal accretion and distribution of adipose tissue in pregnancy.

STUDY DESIGN

Women with normal glucose tolerance and GDM were evaluated before conception, early (12-14 weeks) and late (33-36 weeks) in gestation. Fat mass, lean body mass, and percent body fat were assessed longitudinally with hydrodensitometry. Serial biceps, triceps, subscapular, iliac, costal, mid thigh, and lower thigh skinfold measurements quantified the changes in fat mass distribution. Pregravid obesity was defined as >25% body fat.

RESULTS

Subjects included 19 patients with GDM (5 lean women, 14 obese women), and 33 patients with normal glucose tolerance (controls; 12 lean women, 21 obese women). GDM and control subjects were similar in pregravid percent body fat (29.6% vs 27.9%, P=.47) and fat mass (20.8 kg vs 18.2 kg, P=.37). Values for subjects with GDM and controls were also similar in terms of percent body fat, fat mass, and weight gained (change in percent body fat, -0.7% vs 1.9% [P=.07]; change in fat mass, 3.8 kg vs 5.0 kg [P=.08]; change in weight, 12.0 kg vs 13.2 kg [P=.35]). Lean subjects gained more percent body fat compared with obese subjects (change in percent body fat, 3.3% vs 0.1% [P=.004]) but gained similar amounts of fat mass (change in fat mass, 4.7 kg vs 4.2 kg [P=.58]), lean body mass (7.6 kg vs 8.8 kg [P=.18]), and weight (change in weight, 12.3kg vs 13.0 kg [P=.61]) The distribution of adipose tissue that was accumulated as estimated with skinfold measurements was similar between patients with GDM and glucose tolerance (P>.05 for all changes in skinfolds), but significantly different between lean and obese patients (P<.05 for all changes in skinfolds). Lean women gained a predominance of adipose tissue peripherally over that in obese women.

CONCLUSION

Lean women accrue significantly more fat mass than obese women, regardless of glucose tolerance. Pregestational obesity rather than GDM influences the distribution of adipose accretion.

Intermediate metabolism in normal pregnancy and in gestational diabetes

Complex though integrated hormonal and metabolic changes characterize pregnancy. In the face of progressive decline in insulin action, glucose homeostasis is maintained through a compensatory increase in insulin secretion. This switches energy production from carbohydrates to lipids, making glucose readily available to the fetus. This precise and entangled hormonal and metabolic condition can, however, be disrupted and diabetic hyperglycemia can develop (gestational diabetes). The increase in plasma glucose level is believed to confer significant risk of complications to both the mother and the fetus and the newborn. Moreover, exposition of fetal tissues to the diabetic maternal environment can translate into an increased risk for development of diabetes and/or the metabolic syndrome in the adult life. In women with previous gestational diabetes, the risk of developing type 2 diabetes is greatly enhanced, to the point that GDM represents an early stage in the natural history of type 2 diabetes. In these women, accurate follow-up and prevention strategies are needed to reduce the subsequent development of overt diabetes. This paper will review current knowledge on the modifications occurring in normal pregnancy, while outlining the mechanisms. In this paper, we will review the changes of intermediary metabolism occurring during pregnancy. In particular, we will outline the mechanisms responsible for gestational diabetes; the link between these alterations and associated maternal and neonatal morbidity will be examined.

Pregnancy outcome and prepregnancy body mass index in 2459 glucose-tolerant Danish women

OBJECTIVE

This study was undertaken to investigate the relationship between pregnancy outcome and prepregnancy overweight or obesity in women with a normal glucose tolerance test.

STUDY DESIGN

A historical cohort study of 2459 pregnant women systematically examined for gestational diabetes was performed. Information of oral glucose tolerance test results and clinical outcome were collected from medical records.

RESULTS

The risk of hypertensive complications, cesarean section, induction of labor and macrosomia was significantly increased in both overweight women (body mass index [BMI] 25.0-29.9 kg/m(2)) and obese women (BMI >or= 30.0 kg/m(2)) compared with women who were of normal weight (BMI 18.5-24.9 kg/m(2)). The frequencies of shoulder dystocia, preterm delivery, and infant morbidity other than macrosomia were not significantly associated with maternal BMI.

CONCLUSION

Prepregnancy overweight and obesity is associated with adverse pregnancy outcome in glucose-tolerant women.

Secular trends in neonatal macrosomia in Berlin: influences of potential determinants

To investigate the trend in the prevalence of neonatal macrosomia and to evaluate the influences of potential determinants, key features of 206 308 hospital deliveries (97% of all) in Berlin in the years 1993-99, collected by the Berlin Medical Board, were analysed using SPSS 10.0. After exclusion of multiple births and preterm infants, there was a significant increase over 7 years (P < 0.01) in the prevalence of birthweights >or= 4000 g, maternal age >or= 30 years, height of >or= 165 cm, prepregnancy BMI (body mass index) >or= 26 kg/m2 and pregnancy weight gain> 16 kg, but no substantial trend in the prevalence of recognised diabetes or maternal smoking. The adjusted model (OR [95% CI]) for delivering a newborn >or= 4000 g was statistically significant for post-term delivery (2.56 [2.39, 2.75]), women aged >or= 30 years (1.06 [1.02-1.11]), >or= 165 cm tall (1.94 [1.87,2.01]), multiparae (1.98 [1.91, 2.05]), not smoking in pregnancy (2.03 [1.93, 2.14]), prepregnancy BMI >or= 26 compared with < 20 (4.01 [3.77, 4.26]), pregnancy weight gain >or= 16 kg compared with < 10 kg (3.37.[3.22, 3.53]) and for recognised diabetes (1.85.[1.69, 2.04]). It is speculated that this increase in the prevalence of neonatal macrosomia may contribute to the secular trend of overweight and obesity under affluent living conditions.

Proposed diagnostic thresholds for gestational diabetes mellitus according to a 75-g oral glucose tolerance test. Maternal and perinatal outcomes in 3260 Danish women

AIMS

To study if established diagnostic threshold values for gestational diabetes based on a 75-g, 2-h oral glucose tolerance test can be supported by maternal and perinatal outcomes.

METHODS

Historical cohort study of 3260 pregnant women examined for gestational diabetes on the basis of risk indicators. Information on oral glucose tolerance test results and clinical outcomes were collected from medical records.

RESULTS

There was an increased risk of delivering a macrosomic infant in women with 2-h capillary blood glucose of 7.8-8.9 mmol/l compared with women with 2-h glucose < 7.8 mmol/l. Despite treatment, 2-h glucose of 9.0-11.0 mmol/l and > or = 11.1 mmol/l were both associated with increased rates of macrosomia, spontaneous preterm delivery, hypertensive complications, and neonatal hypoglycaemia. Adverse outcomes tended to be more frequent in women with 2-h glucose > or = 11.1 mmol/l than in women with 2-h glucose of 9.0-11.0 mmol/l.

CONCLUSIONS

The risk for several maternal and perinatal complications increased with the diagnostic threshold for 2-h glucose. Large-scale blinded studies are needed to clarify the question of a clinically meaningful diagnosis of gestational diabetes mellitus. Until these results are available, a 2-h threshold level of 9.0 mmol/l after a 75-g oral glucose tolerance test seems acceptable.

Position of the American Dietetic Association: nutrition and lifestyle for a healthy pregnancy outcome

It is the position of the American Dietetic Association that women of childbearing potential should maintain good nutritional status through a lifestyle that optimizes maternal health and reduces the risk of birth defects, suboptimal fetal growth and development, and chronic health problems in their children. The key components of a health-promoting lifestyle during pregnancy include appropriate weight gain; consumption of a variety of foods in accordance with the Food Guide Pyramid; appropriate and timely vitamin and mineral supplementation; avoidance of alcohol, tobacco, and other harmful substances; and safe food-handling. Prenatal weight gain within the Institute of Medicine (IOM) recommended ranges is associated with better pregnancy outcomes. The total energy needs during pregnancy range between 2,500 to 2,700 kcal a day for most women, but prepregnancy body mass index, rate of weight gain, maternal age, and physiological appetite must be considered in tailoring this recommendation to the individual. The consumption of more food to meet energy needs and the increased absorption and efficiency of nutrient utilization that occurs in pregnancy are generally adequate to meet the needs for most nutrients. However, vitamin and mineral supplementation is appropriate for some nutrients and situations. This statement also includes recommendations pertaining to use of alcohol, tobacco, caffeine, street drugs, and other substances during pregnancy; food safety; and management of common complaints during pregnancy and specific health problems. In particular for medical nutrition therapy, pregnant women with inappropriate weight gain, hyperemesis, poor dietary patterns, phenylketonuria (PKU), certain chronic health problems, or a history of substance abuse should be referred to a qualified dietetics professional.

Trends in smoking and overweight during pregnancy: prevalence, risks of pregnancy complications, and adverse pregnancy outcomes

The prevalence of smoking during pregnancy is decreasing in some, but not all, developed countries, as the prevalence of overweight is increasing rapidly in most countries. During pregnancy, smoking increases the risk of placental abruption, but reduces the risk of preeclampsia, while overweight increases the risks of gestational diabetes, preeclampsia, and cesarean delivery. Both smoking and overweight are associated with dose-dependent increases in risks of stillbirth and very preterm birth (< 32 weeks). From a public health perspective, smoking and overweight today probably represent the most important modifiable risk factors for pregnancy complications and adverse pregnancy outcomes.

The epidemiology of stillbirth

Stillbirths account for an increasing proportion of feto-infant mortality. Yet, causes of stillbirth are rarely reported, and the causes of most stillbirths remain unknown. Few studies focus specifically on the epidemiology of stillbirth. Major risk factors include high maternal age, smoking, and overweight. The prevalence of delayed childbearing and, especially overweight, are increasing in most developed countries. The proportion of stillbirth attributable to overweight is likely to increase.

Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity

The initiation of lactation (lactogenesis II) by the mother must be synchronized to the delivery of the infant, permitting the transition of the newborn from continuous nourishment from the umbilical cord to comparable but intermittent life support from its mother's breasts. The onset of lactogenesis II can be adversely affected by a variety of factors. Over 80% of women who have delivered prematurely and are expressing milk for their infant had a compromised initiation of lactation, that is one or more lactogenesis II markers (lactose, citrate, sodium and total protein) in their milk > 3 SD from the mean of the full-term women on d 5 postpartum. Similarly, the lactogenesis II markers (lactose, citrate and total nitrogen) in the milk of women with insulin-dependent diabetes mellitus take an additional 24 h to attain the concentrations of normal women. The mechanisms that lead to the development of delayed or compromised onset of lactogenesis II in women are poorly understood and require additional research.